Mechanical Thrombectomy for Major Stroke with Low Alberta Stroke Program Early CT Score (ASPECTS): Successful Revascularization Failed to Control Brain Edema and Herniation; Decompressive Craniectomy Was Lifesaving but Hemorrhagic Transformation Limited Recovery

In patients with a low Alberta Stroke Program Early CT Score (ASPECTS) (i.e., 0–5), successful endovascular reperfusion has been shown to be robustly associated with better functional outcome, lower mortality, and less symptomatic intracranial hemorrhage (sICH). Successful endovascular recanalization is also associated with a reduction in infarct-associated edema, in contrast to previous observations of higher edema formation after revascularization. A positive effect of endovascular treatment on infarct edema formation may have a direct impact on the occurrence of malignant infarcts, further neurological deterioration, and the need for decompressive craniectomyDecompressive craniectomy, which would support the case for mechanical thrombectomy (MT) in patients with low ASPECTS and large infarcts. We present our experience with a 57-year-old man with a history of arterial hypertension, dyslipidemia, morbid obesity, and advanced ischemic heart disease who was admitted to the emergency room (ER) of a peripheral coastal city after sudden onset of speech and motor changes followed by vomiting and deterioration of consciousness. On admission to the ER 1 h after stroke onset, he was drowsy with gaze deviation, global aphasia, and right hemiplegia, corresponding to an initial National Institutes of Health Stroke Scale (NIHSS) score of 26. His admission arterial pressure was 220/123 mmHg. He vomited several times and was intubated for fear of aspiration. He received intravenous nicardipine to control his arterial pressure. A cranial CT performed 2 h after stroke onset showed left hemispheric hypodensity, and CT angiography (CTA) confirmed occlusion of the left middle cerebral artery (MCA). Although he was in the early therapeutic window, his uncontrolled hypertension and early ischemic changes were considered contraindications for intravenous thrombolysis. The patient was transferred to our center by air ambulance, and a new CT showed an extensive infarct in left MCA territory (ASPECTS 1) with a small penumbra. CTA confirmed proximal occlusion of the left MCA and a poor collateral pattern. Despite the extent of the infarct, we decided to proceed with thrombectomy. Our considerations included his young age, the relatively short interval between clinical onset and possible intervention, and the possibility of improving his prognosis by preserving the existing penumbra and reducing the risk of developing malignant edema and further neurological deterioration requiring decompressive craniectomy. The patient was admitted to the neurointerventional suite 3.5 h after stroke onset. Stentriever-assisted MT allowed rapid recanalization of the left MCA in a single pass. The patient was transferred to the ICU. He remained intubated, ventilated, and deeply sedated with a normotensive nicardipine drip. Contrast CT obtained 10 h after thrombectomy showed a complete (enhanced) MCA infarct. The patient remained clinically stable for the next 12 h, but then developed left pupil dilation. A second CT showed progressive mass effect. He was taken to the operating room for urgent decompressive craniectomy. Immediately after surgery, his pupils were equal and reactive. A cranial CT performed 12 h after decompressive craniectomy showed herniation of the left hemisphere through the craniectomy and development of multifocal hemorrhages. On a 2-day wake-up test, the patient remained comatose with a strong left-sided localizing response to pain (GCS 7). On admission day 7, the patient underwent bedside percutaneous tracheostomy. On day 8, sedation was tapered and eventually discontinued. On day 9, the patient opened his eyes without gaze deviation but with global dysphasia. He made spontaneous purposeful movements with his left body and responded intermittently to simple commands. Electrocardiographic (ECG) monitoring revealed an episode of atrial fibrillation lasting 3 h. Non-vitamin K oral anticoagulation (NOAC) was started on day 7 after craniectomy. The patient was transferred to inpatient rehabilitation, where he showed slow but progressive neurological improvement. Cranioplasty was performed 9 weeks after decompressive craniectomy. At 90-day follow-up, he was alert and dysphasic, had partial language comprehension, had severe motor dysphasia, and was able to follow simple verbal commands with dense right hemiparesis. He could stand with assistance but was confined to a wheelchair most of the time (90-day modified Rankin Scale [mRS] score 4). This chapter addresses some of the most intriguing issues in modern stroke therapy: the indications and rationale for MT in patients with low ASPECTS, thrombectomy and cerebral edema, and decompressive craniectomy and hemorrhagic transformation.